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SAR S-92 Missing Ireland

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Old 4th May 2017, 11:44
  #1641 (permalink)  
 
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Originally Posted by G0ULI
....it currently looks like a combination of minor operating errors and/or oversights that led to this accident.
Or situational awareness breakdown, for reasons yet to be determined.
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Old 4th May 2017, 11:56
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gulliBell

I re-edited the last paragraph as you were posting, but totally agree with your comment.
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Old 4th May 2017, 12:45
  #1643 (permalink)  
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Originally Posted by ZFD
Both FAA and EASA recognise the import of database integrity.
The following excerpt is an insight on the basic criterion.
"These Conditions establish:
(a) The procedure for the issuance of a letter of acceptance (LOA) for organisations that translate, format and/or integrate information that originates from State aeronautical information services (e.g. AIP) into electronic databases for airborne navigation systems.
(b) The rights and obligations of the applicant for, and holders of, such letters of acceptance.
A.132. Definitions
(a) Navigation Database - Data (such as navigation information, flight planning waypoints, airways, navigation facilities, SID, STAR) that is stored electronically in a system that supports an airborne navigation application.
(b) Data Service Provider – An organisation (not including the State AIP provider), which collects, originates or processes aeronautical data and provides a navigation database in a generic format (such as ARINC 424). Such organisations are eligible for a Type 1 LOA under these Conditions (see Guidance Para 5.7) showing that the generic database has been formatted under controlled conditions.
(c) Data Application Integrator - An organisation that incorporates either State AIP data or a generic database into a format compatible with specific target airborne navigation equipment with a defined intended function. Such organisations require an interface with the equipment design organisation, and are eligible for a Type 2 LOA under these Conditions (see Guidance Para 5.7). This provides a list of equipment models and part numbers where compatibility has been demonstrated to the Agency, permitting the supply of navigation databases directly to end users/operators.
(d) Data Quality Requirements - A specification of the characteristics of data to ensure that data is compatible with its intended use."

https://www.easa.europa.eu/system/fi...e_supp_doc.pdf
However, they have both (knowingly) ignored the lack of regulatory requirements of EGPWS/TAWS updating until now! (Honeywell even still state their is no regulatory requirement to update on their EGPWS DB website).
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Old 4th May 2017, 13:16
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A lot of risk factors have been identified:

· Insufficiently clear APBSS approach guidance chart
· Assumption that existence of APBSS in FMS database meant it was safe at 200ft
· Lack of total clarity of Blackrock height on 1:500,000 VFR chart
· Blackrock in some databases not others, at varying heights
· Blackrock not in EGPWS database
· Probably poor radar operating technique so Blackrock, a 300ft high 700ft wide island, was not seen
· Too slow reaction by crew to FLIR operator warning of Blackrock
· And no doubt several others

BUT.... the existence of all these risk factors would not have mattered at all if the aircraft had been at a sensible height, not 200ft.

To me the main cause of this accident was the crew’s decision to descend to 200ft for a 12 mile transit (including approach to Blackrock) to Blacksod. It should be obvious that the chance of hitting something in poor vis/IMC increases the lower you go, the longer you do it. 10 miles at 200ft is going to carry 10 times the risk of hitting something as 1 mile at 200ft – which should have been all that was necessary for this approach. They could have even used the APBSS route guidance, which at sensible heights would have fine, with a let-down to 200ft to say BKSDB.

The world is too big and changing too fast for any nav databases to be 100% reliable everywhere. Just look at the rash of emerging wind turbines across northern Europe! Approval and verification processes understandably take time and mean databases will lag.

To opt for a flight profile of massively increased danger - and then having to totally rely on a multiple crew trying to use complex systems properly, (eg radar open to misinterpretation) and fallible databases and EGPWS, to keep safe, is just nuts.

Don’t get me wrong – all the risk factors identified need addressing as soon as possible. But to me the immediate safety actions should be reviewing the approach profiles, particularly vertical, that crews use in situations like this. Clearly if you’re looking for a bloke on a surfboard (and great job btw, SAR Prestwick) flying at 200ft is perfect. But not for 10 miles for an approach at night to a refuelling base. And the needing to be 200ft to be VMC just doesn’t add up here – (a) I don’t think many of us think they were, and (b) the chances were always going to be high of areas of further reduced cloud-base – what were they going to do then? Descend further? Climb into it and go IMC? Turn back?

Clearly the crew chose to use this approach type. Following the investigation, it will be very interesting to see what light is shed on just why.
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Old 4th May 2017, 13:56
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Rotorspeed I agree with you 100%. If you choose to fly very low, at night, over the inky black sea and possibly in and out of clouds WITHOUT a rock solid plan to avoid the obstacles (which you must assume will be there). FOR NO GOOD REASON, its just Russian roulette.
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Old 4th May 2017, 14:21
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How do we know they did not have a rock solid plan to avoid obstacles (including Blackrock that was at least 82 feet ABOVE their chosen height)?

What if they did.....but something intervened to undermine their Plan?

We do not know what their Plan was as there is insufficient data in the public domain to make that determination.

Plainly, something happened as they were killed when the aircraft impacted terrain despite there being some warning....as noted by the CVR Transcript.

The key to the puzzle will be in ascertaining why the Crew chose such a height despite the known obstacle provided by Blackrock....and then when warned of the proximity of Blackrock by the FLIR Operator....did not take IMMEDIATE Action to avoid the terrain in front of them.

I would think a review of the Unit SOP's, Crew Briefs for this incident, and a review of other Crew Briefs/Practices by this Crew in particular and the Operation Crews in general will shed a lot of light on how business is done during similar weather/night approaches.

Again, legacy practices , SOP's, and incorporation of new technology issues should be carefully considered.
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Old 4th May 2017, 14:44
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SAS, may I be so bold as to suggest you have missed the salient point.......why 200 feet so far from the destination?

Also the P1 must have had some idea what was around the aircraft to support the comment that was made when they had the RADALT alerts.

To be fair to crew at this stage we should assume they did not actually fly over any red blobs at 200 feet, despite the RADALT warnings. They do not make a clear mention of the red blob that should have been painting for Black Rock.

I guess for me the Map and EGPW Database is way down the list because the regulations clearly state it shall not be used for terrain avoidance.

To place waypoints over an obstacle(s) and then make a route out of it, it begs the question for what purpose exactly was the route intended to serve? A letdown, by any sense of the word, implies you cannot see the ground sufficiently to fly by visual means. It would therefore need to have both horizontal and vertical profiles clearly defined. I have not seen the full procedure for this approach so I do not know if this information is prescribed.

It is a terrible event and likely to have some serious repercussions in the industry about how data is interpreted and the formal priorities that should be given to the systems available in the cockpit.

If memory serves me correctly there was an FSI released by the same Operator just a few years back that demanded crews prioritise the FMS Waypoint ICON in favour of the RADAR return. Needless to say the boys and girls in the cockpit laughed it into extinction but not without some resistance from above.

This could be an example of what goes wrong when assumptions are made and poor cockpit paperwork is generated by desk jockeys and the weight and volume of garbage in the cockpit creates so much white noise that the wood cannot be seen from the trees.
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Old 4th May 2017, 15:00
  #1648 (permalink)  
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That's interesting, so the crew can choose the priorities in the overlay system ?
 
Old 4th May 2017, 15:17
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You know someone once told me that when a pilot gets borne he is issued with 2 buckets. One is full of LUCK and the other is empty but marked "EXPERIENCE". The trick they said was to try and fill up the bucket of EXPERIENCE before the bucket of LUCK ran out.

I got borne in the Army. With a little more than 300 hours in my logbook and the ink still wet, I found myself tasked to fly a General from Soest to Rheindahlen along the affectionately termed "IF Corridor". To achieve this we had a MINITANS Doppler driven NAVAID which liked to **** itself occasionally especially in clouds. (Great). However, being well trained in the basics one had a back-up plan! DR (Dead Reckoning). So when the TANS went AWOL you could probably, fair wind and all that, end up within a howitzers range opf the intended destination. Thank God Laarbruck and Bruggen could "Catch" you at the other end with a nicely timed GCA. However, situated along the corridor, close to it, was Dusseldorf. ZE Germans liked to mess you about. Turn Left, Turn Right, Decend, Climb, etc, all of which we could do cos we was properly trained by the Green Machine! All this in a Whistling Chicken Leg (Gazelle) with no SAS let alone AFCS (which was at the time just a mere twinkling in Aerospatiale's eye).

However, then comes the hideous phrase "Cleared to continue with your own navigation"!. Quick look at Mr TANS and realise he has gone on holiday just when I need him. Holy Moly what do I do next!. Captain Manwaring might not panic but his bucket of Experience had a lot more in it than mine! Suddenly an Angel appears (well a Big hole in the clouds) and I look down and see Rheindahlen. Collective dumped, arse eating the seat cushion, dirty dive through the hole and land.

Siting in the seat gently perspiring I sense a deficit in my LUCK bucket and a small addition to my EXPERIENCE Bucket. This lasts but a few moments until the General (who up to now has been oblivious to the mortal danger) leans forward and says "5 Minutes Late, What's your name Soldier"

I resisted the urge to say "Its printed on my chest you Dork!" as such things usually ends ones career.

Fast forward to 1990. I become a sweaty heaving civilian! Sumburgh, 2 x S61s in the fleet fitted with the dreaded Bog-Roil/Knitting Needle NAVAID (Decca moving map) (Moving haha, hah). Aided and abetted with a Black&White Radar Stormscope thingy smack in the middle of the instrument console.

Sumburgh had no ILS back then and getting home in the fog/low cloud was a simple case of local knowledge matching the shape of the coastline against the RADAR return and slithering along the NDB needle and the Bog Roll wobbling on top of the console hopefully confirming that we were not doing something stupid. (Providing of course it didn't eject the bog roll down the centre aisle of the passenger cabin).

My bucket of experience actually felt like it had something in after that and the bucket of luck was stabilising under the steady guidance of the Sumburgh Old and Bold.

And here we are today. The MINITANS has gone to the great NAVAID repository in the Sky and the Bog Roll....well I hope someone wiped their arse on it before it was finally retired. The knitting needle should really have been used to poke our F***ink eyes out so we were stopped forever from doing dumb things! However this was not to be.

Replacing all those Heath Robinson solutions in favour of Glass Cockpits, Moving Maps (that actually move), FLIRS, Colour RADARS, Terrain Databases and the Great God of the Sky...GPS and in theory our buckets of LUCK should be protected somewhat allowing our buckets of experience to grow steadily until we achieve the status of LEGEND (Like SAS or CRAB) no irony intended and said from the heart boys!.

Of all the challenges we faced in the past, the future does not seemed to have learned very much.

However, I remember back to those days in Sumburgh sat next to a crusty old Captain who had long favoured the Times Crossword over filling in his Logbook, peering over his bifocals at my truly ****e performance and saying...."Keep trying Laddy. One day it will be all right". And the thing is that my bucket of luck was in their care until the day came when I could get it right.

Those old agades:

1.Runway Behind you!
2. Fuel in the Bowser!
3. Death and WRACs! (oops that's not politically correct anymore is it).

For the sake of sanity and in no small measure, to look after our personal buckets of LUCK lets add another one;

4. DONT FLY OVER RED BLOBS (below MSA).

Last edited by DOUBLE BOGEY; 4th May 2017 at 16:56.
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Old 4th May 2017, 15:31
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O&G perspective

Originally Posted by [email protected]
So how would O&G or corporate crews conduct an IMC letdown to Blacksod at night with a 300' cloudbase?
I fly an S92 for O&G. We would not have been permitted to fly an IMC letdown or any type of IAP to Black sod or Black Rock. In order to fly any type of offshore procedure (such as HEDA, OSAP, ARA) we are required to be at least 5nm offshore from any land. We could base a procedure 5nm offshore from Black Rock, but would then be required to meet VFR minimums in VMC towards Black Sod for a landing. While we could have descended to 200', at the end of the IAP we then be required to proceed under visual conditions. Problem would have been that with a 300 OVC at night, we would not have had legal VFR minimums or legal VMC conditions and so would have had to do a missed approach. We are not SAR, so this reflects what an O&G aircraft would do.
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Old 4th May 2017, 15:54
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DB.....you Dog, you!

61, two pilots, all that lovely kit.....an aotopilot of sorts as I recall....sheer luxury! When we was Young Lads we used to dream of having someone to hold our hands!

Now in the S-58T and Wessex fleets....with no autopilot and the same kit you mention that I remember so fondly.....we held our own hands being single pilot!

I suffered with that same Decca (Mk 19 was it?) and the wonderful scroll map stuck together with cellotape with the adhesive properties of Post-It Glue....that ran away every time there was a hint of static in the air....or you really....really needed it ! That was along about 1979 that I was getting the same trade of luck for experience.....that you were getting yours in the 1990's speaks of how technology change has improved over the years.

But....your point is taken...the more things change the more they stay the same!

Usually if we flew into something in those days we had a lot of help doing it by the absence of help in not doing it.

Today, perhaps we have too much help out of complexity and systemic errors.....and we still run into things we should not.

Managing all this fancy kit and seeing it is being fed accurate data and being given correct inputs is where the rub comes.

Every one of us can fall prey to undesired outcomes.

Hopefully, we will see some positive improvements out of this tragedy!
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Old 4th May 2017, 16:52
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SAS our bog roll also had that strange crispy cellotape holding it together. The same quality and texture as Army bog roll used to be. Maybe we should start a new thread titled:

"And suddenly, an Angel appeared" An ode to the Bucket of Luck!

Whatcha think?
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Old 4th May 2017, 17:11
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My Guardian Angels earned their pay and probably deserved Hazardous Duty and Overtime Incentive pay as they certainly earned it!
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Old 4th May 2017, 17:33
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Perhaps one reason we got away with all that stuff was because we were pilots first and systems managers second - I'm not so sure that balance hasn't moved out of kilter in recent years with ever cleverer equipment, reduced training hours and tighter budgets.
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Old 4th May 2017, 18:05
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Originally Posted by [email protected]
Perhaps one reason we got away with all that stuff was because we were pilots first and systems managers second - I'm not so sure that balance hasn't moved out of kilter in recent years with ever cleverer equipment, reduced training hours and tighter budgets.
I'm not convinced the accident rate stats back-up the rose-tinted spectacle view Crab. There's plenty of evidence to show that a lot of aviators didn't 'get away with all that stuff' in the past.

One of the reasons this incident stands out is the very low numbers of fatalities amongst SAR crews (in the UK anyway) in recent years. Thats not to say that there haven't been plenty of occasions when the 'holes' very nearly lined up.
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Old 4th May 2017, 18:17
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I'm not convinced the accident rate stats back-up the rose-tinted spectacle view Crab. There's plenty of evidence to show that a lot of aviators didn't 'get away with all that stuff' in the past.
there is also plenty of evidence that many did and filled their bucket of experience before they emptied their bucket of luck.

A lack of skill in those days was quickly apparent - these days the automation does so much that good systems managers can get through without good handling skills. Look at the airlines where pilots often have to hire light aircraft themselves to keep their hand-flying skills up to scratch - that was from a senior ex-BA training captain!
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Old 4th May 2017, 18:55
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And therein lies the rub. We're at a really tricky stage in the evolution of aviation - getting the optimum blend of automation and manual skills is a huge challenge. There have now been a number of recent high-profile incidents where automation (and semi-automation) have been a significant factor. What is really hard to quantify is the number of incidents that have been avoided through effective use of exactly the same systems.

It's so easy to point the finger of blame directly at the crew in this instance. I suspect cultural and systemic factors will have played a big part in this one.

Simply improving basic handling skills is not the solution and over-simplifies the issue. A holistic approach is required where designers, regulators, operators and crews all have a meaningful input into improving safety margins.

This will no doubt involve painful self-reflection for helicopter SAR in Ireland. Unfortunately, like most complex socio-technical systems, it takes failure to stimulate progress.
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Old 4th May 2017, 18:56
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To address the balance somewhat. I am a big fan of automation! However, it's use has to be developed over concrete foundations and not sand!

Also the SOPS and the regulations are important to a point. However, never let a **** procedure stand in the path of sound airmanship.
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Old 4th May 2017, 21:14
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It's not that I believe handling skills are the simple solution - it is the lack of need for those handling skills, as automation has improved, that makes us lazy and over-reliant on the automation to always 'do the right thing'.

Unfortunately, the automation so regularly does the right thing that we stop questioning it and it takes a major deviation before we wake up and realise our magenta line/heading bug/route steer is taking us to the wrong place.

So perhaps, whilst a great deal of training is used to master and manage the automation to get the best out of it, a certain amount should be spent on recognising and dealing with the insidious nature of its failures.
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Old 4th May 2017, 21:17
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It is the human interface module that seems to be the weak link in this automation thing unless you are riding in one of those Airbus contraptions unlike a Boeing Product that prefers Humans to be the Master over the machine.

Boeing sees a need for the Monkey Skilled Pilot when all else goes pear shaped.
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